Health and Social Care Pathway for people with multiple sclerosis living in West Berkshire
Annette Leach, MS Nurse Specialist, Royal Berkshire and Battle Hospital Trust
Ros Edwards, MS Specialist Occupational Therapist, West Berkshire Council Community Care
Way Ahead 2007;11(1):12-13
This care pathway was developed by the authors and was borne out from the NSF for Long-term conditions, which recommends that people with MS should have equitable access to services and assessments that are timely, with both health and social care services working together to achieve responsive and effective resources as they are needed.
People living with MS need clear information as to how and where they can get services. The multidisciplinary approach (MDT) in West Berkshire encompasses primary, secondary and social care working together to ensure that individuals get the right care at the right time. We have been able to move in this positive direction due to the development of a community-based MS Specialist Occupational Therapist post.
Prior to the MS specialist OT coming into post, the MS nurses were more often left to advocate for patients who struggled to access community care services and resources when they most needed them. Most local authorities operate a system that closes cases at the end of an episode of intervention and have long waiting times for OT assessments. The patients and MS nurses found that accessing community care services was very time consuming and unresponsive, particularly at the time of relapses or deterioration. However, three years on, health and social care services in West Berkshire have moved positively towards providing seamless, responsive services at the time of request.
Initially funded through the MS Society Nurses Fund and West Berkshire Council, the MS specialist OT has been proactive in developing and improving delivery of social care services for people affected by MS. There is now one point of contact for people wanting social care services, which aims to provide a responsive assessment and co-ordinated person-centred approach. Complex cases are not closed but monitored and reviewed to ensure that problems are dealt with efficiently. Close working partnerships with health colleagues, in particular with the MS nurse and MS physiotherapist, were seen as imperative for the MS specialist OT and have proved to be a huge step forward in providing co-ordinated health and social care services.
During the process of developing the care pathway it was agreed that it must be 'person-centred' putting the person at the centre of any assessment, valuing their contribution and listening to and learning about what they want to achieve but also easy to understand.
Having established this approach, we agreed it must be jargon free and include all primary and secondary health and social care services available to people affected by MS, it must demonstrate how each agency can be accessed and by whom. Initially a more complex pathway was drawn up, but on reflection it was agreed that this would be difficult for the person with MS to follow. To simplify the pathway we decided to colour-code the different agencies and minimise the text. We hoped this would clearly indicate how these agencies are separated, although we were careful to link them together to demonstrate how they work in partnership with each other. We decided to keep the text within the care pathway to a minimum, and decided to add an attachment to demonstrate the extent of the MDT approach. This is also colour-coded and linked with the other agencies in the pathway.
Throughout this process we have shared and adapted the pathway with a small group of people affected by MS and other clinicians and have began to distribute it to patients throughout West Berkshire. It is intended that they will keep a copy in their patient-held records along with MS specific information relating to the individuals' needs.
| Medical |
|---|
|
Neurologists MS nurses
Acute treatment |
| Community Health Services |
|---|
|
GPs District nurses Physiotherapy Speech and language therapy Dieticians Chiropody Opticians Complementary therapies |
| Social Services |
|---|
|
Support Advice Independent living equipment and home adaptations Respite Day care Housing advice Benefit advice Advocacy Carers assessments |
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Way Ahead articles are reproduced as published. They are not updated to take account of subsequent developments. Use appropriate caution in acting on the information in any article.
